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The culture result was negative&#44; and the biopsy revealed a bandlike inflammatory infiltrate at both the superficial level and the deep level&#46; This comprised lymphoid cells and occasional nonnecrotizing granulomas with multinucleated giant cells &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41; and was compatible with metastatic Crohn disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Daily topical treatment was started with clobetasol ointment&#44; and the infliximab regimen was intensified temporarily to 4 weeks at the same dose&#46; The lesion healed completely within 2 months&#46; However&#44; erosive crusting lesions appeared gradually at the same site&#46; These progressed slowly until they again became ulcerated &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The infliximab regimen was modified to 6 weeks&#44; and additional treatments were prescribed&#44; as follows&#58; azathioprine 100<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>hours &#40;dose adjusted according to thiopurine methyltransferase levels&#41;&#44; oral prednisone cycles at 0&#46;5-1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; and intralesional triamcinolone infiltrations&#46; This approach was unsuccessful&#46; The infliximab regimen was subsequently intensified to 4 weeks&#44; and metronidazole 500<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>hours was added&#46; Wet-wrap dressings &#40;HydroClean Advance&#41; were applied throughout treatment&#44; and the patient was monitored for signs of superinfection&#46; Despite the treatment prescribed&#44; the ulcers worsened quickly and became larger and deeper &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The patient remained free of digestive symptoms at all times&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given the failure of therapy and the new indication of ustekinumab for Crohn disease&#44; we agreed with the Gastroenterology Department to change the therapeutic target and start treatment with ustekinumab in monotherapy according to the established regimen for Crohn disease and based on the patient&#8217;s weight&#46; The induction dose administered was 390<span class="elsevierStyleHsp" style=""></span>mg followed by 90<span class="elsevierStyleHsp" style=""></span>mg every 8 weeks subcutaneously&#46; Initiation of ustekinumab led to a rapid improvement in the ulcer from the first month and complete cure in 3 months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#44; with no adverse effects&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Metastatic Crohn disease is a rare extraintestinal manifestation of Crohn disease&#46; While no epidemiological data are available&#44; it is the least common specific cutaneous manifestation&#46; The condition is characterized by the appearance of heterogeneous cutaneous and subcutaneous lesions comprising noncaseating granulomata at anatomic sites not contiguous to the gastrointestinal tract&#46; It may precede&#44; co-occur with&#44; or follow the gastrointestinal disease&#46; The lesions can mimic other more common skin conditions&#44; such as impetigo&#44; erysipelas&#44; erythema nodosum&#44; and pyoderma gangrenosum&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical suspicion is essential for biopsy and early diagnosis&#44; since the definitive diagnosis is confirmed by histopathology&#46; The presence of persistent skin lesions in patients with Crohn disease should lead us to suspect this possibility&#44; even if the patient is receiving immunosuppressive or biologic therapy and despite the fact that digestive symptoms have remitted&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">If the patient is receiving treatment with an anti&#8211;tumor necrosis factor &#40;TNF&#41; &#945; agent&#44; monitoring drug levels and antibody testing would contribute to better management of therapy&#44; since we could determine whether drug levels were insufficient and whether the cause was underdosing or the presence of antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Unfortunately&#44; and despite the clinical interest of this approach&#44; the required techniques are not available in many centers or for all biologics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As there is no standard treatment for this condition&#44; management should be tailored&#46; If the lesions are localized&#44; we can consider local treatments&#44; such as topical corticosteroids or tacrolimus&#44; or even intralesional corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> If there is no response&#44; systemic treatment with oral corticosteroids can be considered&#46; If these fail or are insufficient&#44; then conventional immunosuppressants or biologics can be added&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Cases have been treated with metronidazole&#44; mycophenolate mofetil&#44; ciclosporin&#44; adalimumab&#44; infliximab&#44; certolizumab&#44; thalidomide&#44; surgery&#44; and hyperbaric oxygen therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> All of the biologics used were anti-TNF-&#945; antibody agents&#46; The only case reported of Crohn disease involving the genital region &#40;vulvar and perineal&#41; was successfully treated with ustekinumab&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ustekinumab is a monoclonal antibody that targets the p40 subunit of the IL-12 and IL-23 receptors&#46; It has been indicated for Crohn disease since 2017&#46; Given that its therapeutic target is not TNF-&#945;&#44; ustekinumab may prove to be a therapeutic option in patients with metastatic Crohn disease whose treatment with corticosteroids&#44; immunosuppressants&#44; or anti-TNF-&#945; agents has failed&#46;</p></span>"
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Case and Research Letters
Metastatic Crohn Disease Treated With Ustekinumab
Enfermedad de Crohn metastásica tratada con ustekinumab
R. Ballester Sánchez*, C. Sanchís Sánchez, B. Rodrigo Nicolás, F. Valcuende Cavero
Servicio de Dermatología, Hospital Universitari de La Plana, Villarreal, Castellón, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 41-year-old woman was evaluated in the dermatology clinic for an asymptomatic ulcer that had first appeared on her left leg 3 months earlier&#46; The lesion had violaceous borders and a keratotic center &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The patient had fistulizing ileocolonic Crohn disease&#44; for which she had undergone several surgical procedures &#40;total proctocolectomy&#44; resection of the small intestine&#44; and terminal ileostomy&#41;&#46; Her disease was well controlled with infliximab at 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 8 weeks&#44; which she had been taking for the last 9 years&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">A sample was taken for microbiological culture and a biopsy for histopathology&#46; The culture result was negative&#44; and the biopsy revealed a bandlike inflammatory infiltrate at both the superficial level and the deep level&#46; This comprised lymphoid cells and occasional nonnecrotizing granulomas with multinucleated giant cells &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41; and was compatible with metastatic Crohn disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Daily topical treatment was started with clobetasol ointment&#44; and the infliximab regimen was intensified temporarily to 4 weeks at the same dose&#46; The lesion healed completely within 2 months&#46; However&#44; erosive crusting lesions appeared gradually at the same site&#46; These progressed slowly until they again became ulcerated &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The infliximab regimen was modified to 6 weeks&#44; and additional treatments were prescribed&#44; as follows&#58; azathioprine 100<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>hours &#40;dose adjusted according to thiopurine methyltransferase levels&#41;&#44; oral prednisone cycles at 0&#46;5-1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; and intralesional triamcinolone infiltrations&#46; This approach was unsuccessful&#46; The infliximab regimen was subsequently intensified to 4 weeks&#44; and metronidazole 500<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>hours was added&#46; Wet-wrap dressings &#40;HydroClean Advance&#41; were applied throughout treatment&#44; and the patient was monitored for signs of superinfection&#46; Despite the treatment prescribed&#44; the ulcers worsened quickly and became larger and deeper &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The patient remained free of digestive symptoms at all times&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given the failure of therapy and the new indication of ustekinumab for Crohn disease&#44; we agreed with the Gastroenterology Department to change the therapeutic target and start treatment with ustekinumab in monotherapy according to the established regimen for Crohn disease and based on the patient&#8217;s weight&#46; The induction dose administered was 390<span class="elsevierStyleHsp" style=""></span>mg followed by 90<span class="elsevierStyleHsp" style=""></span>mg every 8 weeks subcutaneously&#46; Initiation of ustekinumab led to a rapid improvement in the ulcer from the first month and complete cure in 3 months &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#44; with no adverse effects&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Metastatic Crohn disease is a rare extraintestinal manifestation of Crohn disease&#46; While no epidemiological data are available&#44; it is the least common specific cutaneous manifestation&#46; The condition is characterized by the appearance of heterogeneous cutaneous and subcutaneous lesions comprising noncaseating granulomata at anatomic sites not contiguous to the gastrointestinal tract&#46; It may precede&#44; co-occur with&#44; or follow the gastrointestinal disease&#46; The lesions can mimic other more common skin conditions&#44; such as impetigo&#44; erysipelas&#44; erythema nodosum&#44; and pyoderma gangrenosum&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical suspicion is essential for biopsy and early diagnosis&#44; since the definitive diagnosis is confirmed by histopathology&#46; The presence of persistent skin lesions in patients with Crohn disease should lead us to suspect this possibility&#44; even if the patient is receiving immunosuppressive or biologic therapy and despite the fact that digestive symptoms have remitted&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">If the patient is receiving treatment with an anti&#8211;tumor necrosis factor &#40;TNF&#41; &#945; agent&#44; monitoring drug levels and antibody testing would contribute to better management of therapy&#44; since we could determine whether drug levels were insufficient and whether the cause was underdosing or the presence of antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Unfortunately&#44; and despite the clinical interest of this approach&#44; the required techniques are not available in many centers or for all biologics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As there is no standard treatment for this condition&#44; management should be tailored&#46; If the lesions are localized&#44; we can consider local treatments&#44; such as topical corticosteroids or tacrolimus&#44; or even intralesional corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> If there is no response&#44; systemic treatment with oral corticosteroids can be considered&#46; If these fail or are insufficient&#44; then conventional immunosuppressants or biologics can be added&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Cases have been treated with metronidazole&#44; mycophenolate mofetil&#44; ciclosporin&#44; adalimumab&#44; infliximab&#44; certolizumab&#44; thalidomide&#44; surgery&#44; and hyperbaric oxygen therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> All of the biologics used were anti-TNF-&#945; antibody agents&#46; The only case reported of Crohn disease involving the genital region &#40;vulvar and perineal&#41; was successfully treated with ustekinumab&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ustekinumab is a monoclonal antibody that targets the p40 subunit of the IL-12 and IL-23 receptors&#46; It has been indicated for Crohn disease since 2017&#46; Given that its therapeutic target is not TNF-&#945;&#44; ustekinumab may prove to be a therapeutic option in patients with metastatic Crohn disease whose treatment with corticosteroids&#44; immunosuppressants&#44; or anti-TNF-&#945; agents has failed&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ballester S&#225;nchez R&#44; Sanch&#237;s S&#225;nchez C&#44; Rodrigo Nicol&#225;s B&#44; Valcuende Cavero F&#46; Enfermedad de Crohn metast&#225;sica tratada con ustekinumab&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;182&#8211;183&#46;</p>"
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